BVA9510703
DOCKET NO. 93-12 719 ) DATE
)
)
On appeal from the decision of the
Department of Veterans Affairs Regional Office in Nashville,
Tennessee
THE ISSUE
Entitlement to service connection for a psychiatric disorder
to include post-traumatic stress disorder (PTSD).
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESSES AT HEARING ON APPEAL
Appellant, and his brother
ATTORNEY FOR THE BOARD
John M. Clarkson, III, Associate Counsel
INTRODUCTION
The veteran had active service from February 1969 to February
1971. By rating action of May 1969, the Nashville, Tennessee
Regional Office (RO) denied service connection for PTSD.
This appeal arises from a November 1990 rating action by
which the RO reopened the veteran's claim, but denied service
connection for PTSD. While the RO has phrased the issue as
entitlement to service connection for PTSD, it is clear that
the claim is for service connection for a psychiatric
disorder, however diagnosed.
REMAND
The U.S. Department of Veterans Affairs (VA) has a duty to
assist the veteran in the development of facts pertinent to
his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R.
§ 3.103(a) (1994). The U.S. Court of Veterans Appeals
(Court) has held that the duty to assist the veteran in
obtaining and developing available facts and evidence to
support his claim includes obtaining medical records to which
the veteran has referred and obtaining adequate VA
examinations; the Court has also stated that the Board must
make a determination as to the adequacy of the record.
Littke v. Derwinski, 1 Vet.App. 90 (1990). Fulfillment of
the statutory duty to assist includes the conduct of a
thorough and contemporaneous medical examination, one which
takes into account the records of prior medical treatment, so
that the evaluation of the claimed disability will be an
informed one. Green v. Derwinski, 1 Vet.App. 121 (1991).
Moreover, with respect to PTSD claims, the Court has held
that the question of whether a specific event reported by a
veteran as a stressor is a question of fact for the Board to
decide. Wilson v. Derwinski, 2 Vet.App. 614 (1992).
The appellant contends, in effect, that he suffers from PTSD,
as a result of combat conditions. During his military
service in Vietnam, the veteran was assigned to a supply and
armor unit. He testified that he came under hostile fire in
June or July of 1970 during which time he suffered a nervous
breakdown and was medivaced out of Vietnam. It appears that
the date of the alleged stressful event is incorrect as
reported by the veteran since the service medical records
reflect he was admitted to a hospital on June 1, 1970 for
psychiatric evaluation. Thus, the alleged stressor must have
taken place in late May 1970. The RO has concluded that the
evidence did not show a traumatic incident during military
service which would constitute a stressor; however, this was
done without referral to The U.S. Army and Joint Services
Environmental Support Group (ESG).
On several occasions, the veteran has been diagnosed by VA
examiners as having PTSD, but a diagnosis of PTSD referenced
in a discharge summary of April 1989 does not appear in the
record. The record indicates that the veteran received
treatment for a variously diagnosed psychiatric disorders
including , including PTSD, from VA medical centers (VAMCs)
in Nashville, Tennessee and Murfreesboro, Tennessee. A
December 1992 report from the Murfreesboro VAMC suggests that
the veteran could be seen as an outpatient after that date.
However, the record does not indicate whether all records of
treatment for PTSD at the Nashville VAMC are in the record,
and the record does not indicate whether the veteran received
additional treatment from the Murfreesboro VAMC after
December 1992. The record is replete with a number of
diagnoses concerning the veteran’s psychiatric disability and
at this point, there is no certainty as to the proper
diagnosis(es).
Additionally, during the hearing on appeal, the veteran
stated that he is receiving Social Security benefits, but the
underlying medical records upon which the Social Security
award was based are not included in the record and the record
does not disclose whether VA examiners possessed the records
relied upon by the Social Security Administration in making
its disability adjudication.
Given the foregoing the Board notes that it is unclear
whether the veteran is suffering from PTSD. The Court has
held that the Board must consider only independent medical
evidence to support its findings, rather than provide its own
medical judgment in the guise of a Board opinion. Colvin v.
Derwinski, 1 Vet.App. 171 (1991).
Under these circumstances, we find that additional
development is required, and the case is REMANDED to the RO
for the following:
1. The RO should contact the Social
Security Administration and obtain a copy
of the Social Security decision awarding
disability benefits to the veteran as
well as copies of all underlying medical
records upon which the decision was
based. All records obtained should be
associated with the claims folder.
2. The RO should contact the
Environmental Support Group in order to
ascertain whether the veteran
participated in a firefight in late May
1970 while on a mission in Fantiet,
Vietnam.
3. The RO should obtain all records of
medical treatment of the veteran from the
Nashville VAMC and any additional records
of medical treatment of the veteran which
may have been generated by the
Murfreesboro VAMC after December 1992.
All records obtained should be associated
with the claims folder.
4. After all of the above referenced
records have been obtained, the veteran
should be afforded a psychiatric
examination by a board of two
psychiatrists. Such tests as the
examining psychiatrists deem necessary
should be performed, to specifically
include psychological testing, in order
to ascertain the proper diagnosis(es) of
any psychiatric condition present. If
PTSD is diagnosed, the examiners must
specify the stressor to support the
diagnosis. The claims folder must be
made available to the examining
psychiatrists prior to the examination so
that the examiners may review pertinent
aspects of the veteran's military and
medical history.
5. Following completion of the
foregoing, the RO must review the claims
folder and ensure that all of the
foregoing development actions have been
conducted and completed in full. If any
development is incomplete, including if
the requested examination does not
include all test reports, special studies
or opinions requested, appropriate
corrective action is to be implemented.
After completion of these actions, the RO should review the
evidence and determine whether the veteran's claim for
service connection may now be granted. If not, the veteran
and his representative should be furnished an appropriate
supplemental statement of the case, and the case should be
returned to the Board for further appellate consideration.
C.W. SYMANSKI
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1994).